Four early stages in the development of mother-infant interaction

Mother-Infant Dyadic Synchrony in the NICU Context

BACKGROUND

Dyadic synchrony is a co-constructed social process relating to the back and forth interactions between mothers and infants that are strongly associated with neurodevelopment, self-regulation, and attachment. In the neonatal intensive care unit (NICU), this process may become interrupted because of the physiological state of the infant, the emotional state of the mother, and the physical environment of the NICU.

PURPOSE

In applying Feldman's Biobehavioral Model of Synchrony, this empirical review deconstructs the process of dyadic synchrony in the NICU context and provides a conceptual approach to guide both research and clinical practice.

METHODS

First, we examine the theoretical and empirical literature to explicate the primary structural and biophysiological components of synchrony and relate these constructs to the extant research on premature infants. Next, we synthesize the maternal, infant, and contextual factors that facilitate or inhibit the ontogenesis of dyadic synchrony in the NICU. The final section highlights the state of the science in dyadic synchrony in the NICU including gaps and recommendations for future research.

FINDINGS

An empirical review synthesis presents a visual conceptual framework to illustrate multiple processes that depict maternal, infant, and contextual influences of mother-infant synchrony in the NICU.

IMPLICATIONS FOR PRACTICE/RESEARCH

Despite the challenges posed to mother-infant relationships in the NICU, high-quality mother-infant interactions are possible, dyadic synchrony can emerge, and premature infants can develop secure attachments. Clinicians and researchers can apply this conceptual framework of mother-infant dyadic synchrony in the NICU to promote evidence-based research and clinical practice.

Interweaving social and manipulative development in early infancy: Some direction for infant caregiving

Early infancy has been neglect not having the best opportunities to promote social motor and cognitive development. The maturational concept considering young infants as passive beings provide a misguided view of the developmental process. The human infant is an active being from the very beginning of life. In the social and physical world, they can, by observing and imitating, perform complex actions involving different motor behaviours. In the present review we argue that imitation and manipulative actions are integrated in Expressive Action System (Reed, 1996) where baby-caregiver social interaction is the link between the use and exploration of objects in the world. We present evidence that neonatal imitation and manipulation activities are connected and thus, we propose stimulation practices based in seminal experimental designs where infants should be positioned in favourable postures to observe others acting in the world. This will have an impact on the way that early infants understand the social world and the chain of actions possible in this environment.

Enfant persécuteur ou enfant sauveur ? Quand trauma et migration s’amalgament à l’ambivalence de la mère dans la relation à son bébé

La grossesse est un moment de remaniements psychiques et identitaires fragile, où l’ambivalence de la mère est nécessaire et structurante pour l’enfant à venir. Mais qu’en est-il de l’ambivalence lorsque la mère est aux prises avec des traumatismes ? Quel est le rôle de la migration et de l’exil dans le fait de donner naissance dans un monde nouveau ? Quels impacts pour l’enfant et pour sa « continuité d’exister » ? C’est à la lumière de situations cliniques issues d’une recherche portant sur la transmission transgénérationnelle du trauma de la mère à l’enfant auprès de mères migrantes que ces questionnements ont surgi et que leur approfondissement s’est imposé comme une réponse à une réalité clinique souvent rencontrée en périnatalité auprès des populations immigrantes et réfugiées. L’acte de transmettre la vie prend racine dans l’histoire des mères et vient questionner leurs identités, leurs filiations et leurs affiliations mises à l’épreuve par l’adversité rencontrée. L’arrivée des enfants est à la fois fragilisante et source de « résilience » exceptionnelle. Il est donc essentiel de penser la question de l’accueil de ces dyades mère-bébé pour des soins adaptés et culturellement sensibles.

The Affectionate Bond

The role of empathy in promoting emotional closeness between two individuals has been well established. It is a significant component of various forms of individual psychotherapy and has also been recognized as important to promoting growth in parent-child, teacher-student, manager-staff, and other relationships. The authors have incorporated this conceptualization of empathy into a couple-centered approach to relationship difficulties. Reciprocal empathy promotes emotional disclosure, which leads to increased intimacy and an affectionate bond between partners.

Feeding Assessment: Development of a Biopsychosocial Instrument

This article proposes that behavioral and sociocultural factors are important in assessing the feeding of at-risk children. In describing an instrument to assess maternal and child behaviors during feeding the article challenges therapists who work with at-risk children in the area of oral-motor intervention to broaden their conceptual framework for practice to include psychosocial as well as biological factors in their feeding assessment and intervention Qualitative methodology consistent with this biopsychosocial perspective is described as it was used to formulate an assessment tool for measuring concurrently the interaction of caregiver and child in conjunction with the oral-motor performance of the child. The resulting Feeding Interaction Report-Scale and Treatment is described in its initial stages to facilitate understanding of the reciprocal nature of parent and child interaction in activities of daily life. The pilot use of the scale with 14 at-risk 2- to 40-month-old children and their parents is reported. Results indicate that although this line of assessment is in its formative stages, it may elucidate an important direction in clinical understanding of the way parents and children interact and develop.

Mother-infant synchrony during infant feeding

PURPOSE

The purpose of this study was to test a coding system, the Maternal-Infant Synchrony Scale (MISS), for assessing synchrony of feeding interaction between a mother and her preterm infant. The secondary aim was to describe mother and preterm infant synchrony during feeding and the change over time.

METHODS

A descriptive, longitudinal design using data collected during an earlier study was employed, using a sample dataset from 10 mother-infant dyads that completed three data collection points. The Noldus Observer XT 8.0 (Noldus Information Technology b.v., 2006) was used for data review and coding. The MISS was created from pilot data and definitions further refined. The frequency of occurrence for select behaviors and the percentage of time behaviors occurred during the feeding and the changes in behaviors over the three observations periods were calculated.

RESULTS

The synchrony tool developed in this study demonstrates that changes occur in mother and infant behavior over time. Mothers were attentive and focused during feedings and monitored their infants' sucking intently but there was little interaction between the dyad. Infant attempts at interaction were greater than the mother attempts to engage her infant. The influence of infant maturation on feeding behaviors was evident across observations.

CONCLUSION

This study revealed behaviors that are descriptive of the interaction and can be used to develop interventions that would support the developing relationship. Use of the MISS with a larger sample size and a cohort of healthy, term newborns is needed to establish the MISS as a valid and reliable measure of synchrony.

Shame veiled and unveiled: the shame affect and its re-emergence in the clinical setting

The paper examines the psychoanalytic theory of shame and the importance of developmental aspects of the shame affect. In a clinical setting, the discovery of the shame affect, stemming from unconscious and early traumatic situations, is an important and useful approach in helping the patient access painful memories and defenses against them. The defenses disguise the underlying shame affect; furthermore, vision is being bound up with the searing painful affect of shame. The anticipatory dread of scornful gaze of another person, similar to objective self-awareness can cause mortification. Fear of mortification and being exposed emerges in the clinical setting. Through the recognition of enactments in the transference and countertransference interchange, the analyst helps the patient working through them. Several case vignettes demonstrate these important concepts. Finally, the author discusses how shame in certain situations can be a powerful, positive motivator for human interactions.

Mother-infant synchrony

Synchrony is an essential component of the interaction between a mother and her infant and is characterized by adaptive and reciprocal behaviors that promote a mutually rewarding interaction. It is an antecedent for the emergence of self-regulatory function in infants and influences current and future interactions. Understanding the dynamics of the mother-infant dyad and identifying synchronous patterns are important for promoting a healthy relationship. Approaches to measurement and challenges to model development are described.

Surgical treatment of undescended testes

The mainstay of therapy for undescended testes is operative treatment within the first years of life in order to avoid ongoing testicular degenerative changes. The surgical therapy for the palpable undescended testis is orchiopexy and when the testis is non-palpable, a supplementary laparoscopic approach. Success of orchiopexy for inguinal testes has been >95% and for abdominal testes >85-90% in most series.

CONCLUSION

Operation within the first year of life is a safe therapy for undescended testes.

Dissociation following traumatic medical treatment procedures in childhood: A longitudinal follow-up

Chronic illnesses often involve repeated hospitalization and invasive treatment procedures that can have a traumatic impact on child development. To explore possible consequences of treatment procedures, three groups of patients with congenital anomalies were examined longitudinally. At first admission, adolescents (ages 10-20, mean 15) with anorectal anomalies (n = 14), adolescents with Hirschsprung disease (n = 14), and hospitalized controls (n = 14) were assessed for treatment procedures, somatic function, mental health, and dissociative experiences. The assessment included the Adolescent Dissociative Experiences Scale (A-DES). At 10-year follow-up, the patients completed the Dissociative Experiences Scale (DES) and the Somatoform Dissociative Questionnaire (SDQ-20). Anal dilatation, an invasive medical treatment procedure performed daily by the parents the first 4 years, was correlated with the frequency and severity of persisting dissociative symptomatology. The procedure was the only significant predictor of A-DES and SDQ-20 scores, and one of two significant predictors of DES scores. This "experiment of nature" permitted a specific and unique opportunity to examine the impact of early traumatic exposure on child development in the absence of parental malevolence, and on later dissociative outcome in adolescence and adulthood. The findings might be valuable theoretically to our understanding of the development of psychopathology, and may lend itself for comparison with data on sexually abused children.

Skin exposure during conventional phototherapy in preterm infants: A randomized controlled trial

OBJECTIVE

To assess the effect of reduced skin exposure in preterm infants receiving overhead phototherapy treatment on total serum bilirubin (TSB).

METHODS

Randomized controlled trial. Preterm infants (>1500 g birthweight and < or = 36 weeks gestation) were randomized to being nursed either partially clothed with only disposable nappies and in posturally supported positions (n = 30) or naked without postural support (n = 29). Primary outcome was mean TSB percentage change at 24 h of completed conventional overhead phototherapy treatment (irradiance of 6 microW cm(-2)/nm at a wavelength of 425-475 nm). The incidence of rebound jaundice, number of infants continuing to receive phototherapy treatment at 24 h periods, parental stress, mother-infant interaction and mean TSB percentage change at 24 h of completed conventional overhead phototherapy treatment were examined.

RESULTS

Mean TSB percentage change at 24 h of completed treatment for the partially clothed group was 15.4% (+/-18) and for the naked group 19% (+/-15) (mean difference 3.6% 95% CI -5.1, 12.3). No other outcomes were significantly affected by reduced skin exposure to overhead phototherapy treatment.

CONCLUSION

Our results show no statistically significant difference in TSB level change using either nursing practice.

Individual and group psychotherapy with infertile couples

After reviewing some of the relevant literature, the writers proceed to describe a new development in psychotherapy for couples presenting with relatively unexplained infertility. Several couples who had failed to achieve conception (despite the use of assisted reproductive techniques and personal psychotherapy) were brought together into a supportive-expressive group led by the writers, an experienced analytic cotherapy couple. An interesting outcome is described, and mention made of current plans for a future research project.

The psychogenic factor in infertility

The influence of the psyche upon human fertility continues to be underestimated by many workers in the field. For certain individuals and couples there appears to be an unconscious link between a lowering of the level of fertility, and psychosocial, interpersonal or intrapsychic situation rendering it an unsuitable time to allow a baby to come. Such matters need to be explored in an unhurried way. We need time also for a gradual integration of findings from many related fields of knowledge. These issues are discussed and three case studies presented.

The horror! The horror! Reflections on our culture of violence and its implications for early development and morality

This commentary draws on two dimensions of chronic community violence, with thoughts that have been mobilized by the foregoing contributions. One concerns the importance of culture and the other concerns the importance of thinking about early development. Culture permeates all of our actions, and we are in a culture of violence. In other papers in this issue, Richters and Martinez point out that the United States is the most violent country in the industrialized world, and Ciccheti and Lynch state that violence "is becoming a defining characteristic of American society." We are fascinated by violence and in an implicit way we love violence-a fact that we need to acknowledge. Our fascination with violence in American culture is permeating and deep, and, as horrible as it is, I believe we need to face it in order to try to counter it.

The moment of recognition. Rabbinic discourse, infancy, and psychoanalysis

Professionals and educated laymen agree that the past 30 years have brought about a revolution in our understanding of infant development during the very first months of life. The inchoate "blooming buzzing confusion" once felt to characterize the neonate has given way to a well-documented realm of finely tuned perceptions and highly complex interactions. These shifts in our thinking are generally assumed to imply that periods chronologically more remote from our own are conceptually more remote from our modern achievements. But in fact, they are not. I here examine ancient and medieval rabbinic texts and find these "modern" issues discussed. The formulations of these texts, I suggest, sharpen the psychoanalytic focus on the role of the integrative function in very early development.

Developmental psychology and psychoanalysis: I. The context for a revolution in psychoanalysis

After describing the manner in which the integration of psychoanalysis and developmental psychology became a central problem for ego psychology, the author examines the conditions that make it possible for new research and theory in developmental psychology to contribute to a revolution in contemporary psychoanalytic theory. They include: (1) the emergence of a state of "crisis" in American psychoanalysis centering on questions of the nature of early development and how it can be known; (2) the explosive growth of developmental research on early childhood dealing with issues at the heart of that crisis; and (3) the presence of a new generation of psychoanalysts and psychoanalytically oriented researchers capable of bringing that research to bear on those issues.

Maternal role preparation

The Maternal Role Preparation (MRP) project demonstrates an innovative occupational therapy approach to increasing maternal competence in first time mothers. This four session program provided women with discussion, demonstration, practice and written materials covering topics concerning their infants (attachment, sensory systems, developmental abilities) and themselves (acquiring a new role as mother). Theoretical constructs from Behavioral Pediatrics, Sensory Integration and Occupational Behavior were evaluated for their compattbility and combined under the unifying framework of Occupational Behavior. The program represents an opportunity for occupational therapists to combine sensory integration theory and practice with other compatible treatment perspectives and approaches.

Variables Related to Adaptation to Motherhood in “Normal” Primiparous Women

A descriptive study found that of 20 healthy, normal primiparas 25% experienced a very difficult adaptation to motherhood. Previous experience with infants and children, perception of support from postpartum nurses and husbands, help during the first week at home, and postpartum self-concept were found to be related to adaptation in this sample. Nursing implications and interventions for the normal pregnant woman and new mother are discussed.

Abuse and deprivation in failing adoptions

Twelve children seen in psychiatric consultation by the authors over a 3-year period were failing in their adoptive placements. All twelve had been adopted as older children (average age at adoption 5 1/2 years). Ten out of the 12 were males. A retrospective case review demonstrated that all the children shared several common characteristics: (1) a history of both neglect and abusive treatment during at least the first two years of life, (2) a behavioral pattern that was intermittently provocative and punishment seeking, and (3) an ability to elicit a sense of bewilderment and betrayal in the adoptive parents. Twenty-one months was the average duration of the adoption before the families sought the consultation. These adoptive families were all considered competent by the agencies involved. All had raised other natural and adoptive children successfully. Treatment offered by the authors seemed to be helpful in salvaging 4 of the 12 adoptive placements. The authors present these cases as a way of drawing attention to much needed research, both in better understanding the early attachment process in "older child" adoptions, and in better understanding the relative impact of abuse in influencing the child's subsequent attachment capacities.